Differential Diagnosis for the Hip

Question 1

Differential Diagnosis

What should we ALWAYS do to determine if it is the cause of hip symptoms ?

Answer 1

Always screen Lumbar Spine movement and provoke the spine to determine if it is the cause of hip symptoms.

Question 2

Differential Diagnosis

What am I = ?

• Male, 54 y/o
• Buttock pain
• Decreased hip flexion & IR
• (+) Hip SCOUR
• (+) Stinchfield test

Think classification, characteristics, therapy and exercise

Answer 2

Hip OA

(a) Classification:

• Hip Osteoarthritis
• Hip DJD
• End stage Osteoarthritis (ESOA)

(b) Characteristics:

Pain Pattern =

• Buttock Pain
• Pain with weight bearing

Risk Factors =

• Male
• Over 50 y/o
• ↓ ROM hip IR & flexion
• Heavy loads / Physical Work
• History of labral or congenital hip conditions.
• FAI also sets up OA
• Higher BMI

Observation =

• ↓ overall hip ROM
• ↓ hip flexion & IR (most limited)
• Morning stiffness, w/ progression to limp.
• Trendelenburg
• Examination =
• (+) Hip SCOUR
• (+) FADIR
• (+) FABRE
• (+) Stinchfield test

• Flex. - 120
• Ext. - 30
• Abd. - 45
• Add. - 20
• Ext. Rot. - 45
• Int. Rot. - 45

Question 3

Differential Diagnosis

Hip OA:

• Manual Therapy = ?
• Therapeutic Exercise = ?

Answer 3

(c) Manual Therapy:

Joint Mobilization

• Mobilizations for all ROM
• Hypomobility in hip IR, ER, and flexion.
• LE Traction & tractional manipulation
• Contract-relax stretching

STM/MFR

• Treat associated / co-occurring soft tissue dysfunction in glutes, piriformis, hip rotators, and hip flexors w/ cross friction, pin & stretch, ischemic compression, and sustained release techniques.

(d) Therapeutic Exercise:

Motor

• Joint mobility & flexibility exercises all ROM.
• Gluteal strengthening
• Beginner: Glut sets, supine hip snow angel (abd/add), isometrics, bridges, LE PNF patterns.
• Intermediate: Squatting & lunging in available ROM, bridging off one leg, hip IR & ER rotation mobility.
• Advanced: SL RDL’s, SL squats, SL step downs, side-planks with hip abduction.

Sensory:

• Balance retraining & proprioceptive awareness.
• Adding multi-task skills to previous therex activities.
• Core strengthening

Question 4

Differential Diagnosis

True or False:

• Radiographic evidence of hip OA is a good marker of someone’s function and pain ?

Answer 4

• Radiographic evidence of hip OA is NOT a good marker of someone’s function and pain.
• Some individuals with hip OA do not have pain, some without OA have hip pain.

Question 5

Differential Diagnosis

Hip Osteoarthritis:

• What ages are at greater risk = ?
• What pathologies are associated with development of OA = ?

Answer 5

Hip Osteoarthritis:

• Most common hip problem in adults.
• Degenerative changes of articular cartilage and subchondral bone.
• Prevalence rate is up to 27% of adults.
• Biggest risk factor for OA is age.
• Middle aged and older adults; ages 60-74 are at greater risk.
• Occupations lifting heavy loads over a long duration.
• Related to a larger BMI
• Developmental disorders can influence onset and progression.
• Dysplasia, retroversion, anteversion, coxa valga/vara, labral pathologies are associated with development of OA.
• Cutting and running sports may be a risk factor.

Question 6

Differential Diagnosis

These variables make you think = ?

• Acetabular retroversion
• Older age
• Loss of hip IR
• Higher BMI
• Male

Answer 6

Hip OA:

(a) Anatomical Features:

• Acetabular retroversion is associated with OA.
• Cartilage defects and bone marrow lesions in anterior and central superiolateral regions of joint may lead to development of hip OA.

(b) Risk Factors:

• Hip development disorders
• Developmental Dysplasia of hip (DDH)
• Older age
• Loss of hip IR
• Higher BMI
• Male sex

Question 7

Differential Diagnosis

Clinical Prediction Rules for diagnosing hip OA = ?

Answer 7

Clinical Prediction Rules for Diagnosing Hip OA:

(I) First version of CPR:

• Hip IR less than 15 degrees
• Hip flexion less than 115 degrees
• Age greater than 50

(II) Second version of CPR:

• Hip IR less than or equal to 15 degrees.
• Pain with hip IR
• Duration of morning stiffness of the hip less than 60 minutes
• Age greater than 50 y/o

(III) 3rd version:

• Self reported squatting as aggravating factor
• Active hip flexion causes lateral hip or groin pain
• (+) SCOUR test, and lateral or anterior hip pain
• Active hip extension causes pain.

Passive IR less than 25 degrees

Flex. - 120
Ext. - 30
Abd. - 45
Add. - 20
Ext. Rot. - 45
Int. Rot. - 45

Question 8

Differential Diagnosis

Five variables associated to radiographic evidence of hip OA = ?

Answer 8

Five variables associated to radiographic evidence of hip osteoarthritis:

1. Self reported squatting as aggravating factor
2. Active hip flexion – causes lateral hip or groin pain
3. Scour test (+) - lateral or anterior hip pain
4. Active hip extension causes pain
5. Passive IR less than 25 degrees

Question 9

Differential Diagnosis

Impairments in people with hip OA = ?

Answer 9

Impairments in people with hip OA:

• Decreased ROM (Globally but specifically Flexion and Internal Rotation)
• Balance Disturbances
• Muscle tightness - Hip flexors and rotators
• Muscle weakness

Question 10

Differential Diagnosis

Hip OA special test include = ?

Answer 10

Hip OA Special Test:

• FADIR
• Scour
• FABER
• Stichfield test (resisted STLR)

Question 11

Differential Diagnosis

Describe how to carry out FADDIR Test = ?

Answer 11

FADDIR Test:

(a) Client Position:

• Supine with bilateral legs lying extended and arms relaxed at side

(a) Clinician Position:

• Standing next to leg to be assessed, directly facing the client

(c) Movement:

• The combined motions of flexion (typically about 90°) and adduction to end range are initially performed as shown.
• The clinician then maintains adduction with overpressure while performing IR of the hip with overpressure to that motion as well.

(d) Assessment:

• Reproduction of the client’s concordant groin pain and/or clicking or popping with concordant pain is suggestive of hip impingement or labral tear.
• This combined movement engages the femoral head–neck junction into the anterior superior labrum and acetabular rim.
• It is suggested that this combined motion causes a mechanical abutment of the femoral head on the acetabulum and/or shearing force on the labrum.

Question 12

Differential Diagnosis - Treatment for OA:

Most patients eventually progress to = ?

Answer 12

Treatment for OA - Progression and Management:

(a) Most patients eventually progress to total hip replacement.

(b) Management for Hip OA:

• A level evidence for manual therapy – short term relief
• A level evidence for exercises – flexibility and strengthening
• C level evidence for balance training
• B level Patient education
• B level evidence for ultrasound

Question 13

Differential Diagnosis

Objective Measures for the Hip:

• Self report outcome measures = ?
• Functional Tests = ?

Answer 13

(a) Self report outcome measures:

• Hip disability and osteoarthritis outcome score (HOOS)
• Western Ontario McMaster University Index
• Visual Analog Scale
• Lower Extremity Functional Scale
• Harris Hip Score

(b) Functional Tests

(b.1) 30 second chair stand test:

• Sit to stand out of chair in 30 seconds
• 12.6 sit to stand (in hip OA population)
• Minimal detectable change (3.5 reps)

(b.2) Step Test:

• Feet placed on the ground
• The uninvolved foot started from the ground and then up to the step as many times as possible in in 15 seconds
• Compare to the uninvolved side
• Should complete 14 or more steps

(b.3) Timed Single-Leg Stance

• Single limb balance compare bilaterally

(b.4) Berg Balance Assessment

Question 14

Differential Diagnosis

Hip Femoral Acetabular Impingement:

• Classification = ?
• Characteristics = ?

Answer 14

Hip Femoral Acetabular Impingement:

(a) Classification:

• FAI
• Hip Impingement
• Cam Lesion
• Pincer Lesion
• Pistol Grip Deformity of the hip

(b) Characteristics:

Groin Pain:

• Pain with end range of motion at the hip
• Stiffness in younger patient unlikely to have OA
• Progresses to limping

Risk Factors:

• Between 25-50 y/o
• Rigorous sports with end range of motion, twisting, pivoting
• Prior history of hip strain or trauma
• male gender slightly more common than females but later onset FAI may be more common in females in 40’s.

Observation:

• Decreased Hip ROM
• Pain

Examination:

• (+) FADIR
• (+) FAIR test
• (+) FABRE
• End range hip mobility restrictions and pain especially with IR.

Question 15

Differential Diagnosis

What should the manual therapy and therapeutic exercise for Hip Femoral Acetabular Impingement include ?

Answer 15

Hip Femoral Acetabular Impingement - Manual Therapy & Therapeutic Exercise:

Joint Mobilization:

• Perform mid-range mobilizations for all hip ranges of motion.
• Address hypomobility in the hip, avoiding end-range pain with mobilization.
• Consider LE Traction.
• Administer Soft Tissue Release to hip flexors and deep hip rotators.

Soft Tissue Mobilization/Myofascial Release (STM/MFR):

• Target associated/co-occurring soft tissue dysfunction in glutes and deep hip rotators using techniques such as Cross Frictional Release, Pin and Stretch, and Ischemic Compression.

Therapeutic Exercise:

- Motor:

• Utilize Isometric Control and Coordination exercises to limit end-range contact.
• Perform strengthening exercises within pain-free mid-range and end-range motion, avoiding overly vigorous stretching/flexibility exercises.
• Focus on strengthening glutes, short hip rotators, and core stability with combined exercises.
• Exercise examples include Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, and Hip flexor mobility within pain-free range.

- Sensory:

• Implement Balance retraining for control of hip joint and distal Lower Extremity (LE) to reduce hip forces.
• Incorporate additional cognitive, visual, or auditory tasks into therapeutic exercises.
• Introduce Blazepod training and Hip alphabet exercises for sensory enhancement.

Question 16

Differential Diagnosis

Hip Acetabular Impingement:

• Pincer lesion = ?
• Cam lesion = ?

Answer 16

Hip Acetabular Impingement:

(a) Structural variations of femur and or acetabulum.

• Can have labral tear with impingement.

(b) Avoid activities of impingement;

• End range flexion
• IR

(c) Classified as;

• Pincer
• CAM
• Combo (pistol grip deformity)

Question 17

Differential Diagnosis

What am I = ?

• Pain in groin,
• Pain in anterior & lateral hip,
• Pain w/ flexion, adduction, and internal rotation
• Hip IR < than 20 degrees at 90 degrees of flexion
• “Popping” , “Clicking” , “Locking”

Answer 17

Diagnosis and Classification of Hip Impingement:

• Pain in anterior hip/groin
• Pain in lateral hip
• Achy or sharp pain
• Pain w/ flexion adduction internal rotation (FADIR)
• Hip IR less than 20 degrees at 90 degrees of flexion
• Signs and symptoms: “popping”, “clicking” , “locking”

Radiological features:

• Alpha angle greater than 60 degrees
• Crossover sign for hip retroversion

Question 18

Differential Diagnosis

Treatment for Hip FAI includes = ?

Answer 18

Treatment for Hip FAI:

(a) Avoid end ranges of motion/stretching

• Focus on better control of mobility.

(b) Start with isometrics and controlled segmental movements

• Progress to stretching with limitations on how vigorous it is performed.

(c) Strengthening:

• Beginner: Glut sets, Supine hip snow angel (abd/add), isometrics, bridges, piriformis & hip flexor stretching avoiding terminal range if painful, LE PNF patterns, Clamshells, core control exercises.
• Intermediate: Squatting & lunging in available ROM, Bridging off one leg or on Swiss ball, Hip IR & ER rotation mobility, lateral band walking, pelvic drops off step.
• Advanced: Single leg RDL’s, Single leg squats, Single leg step downs, Side-planks with hip abduction, Y balance, 3 way lunges,

Question 19

Differential Diagnosis

Hip Labral Pathology:

• Classifications = ?
• Characteristics = ?

Answer 19

Hip Labral Pathology:

(a) Classification:

• Hip Labral Tear
• Femoral Acetabular Labral Tear

(b) Characteristics:

Pain Pattern =

• “Clicking”, “Popping” , “Catching”
• Anterior hip
• Groin Pain
• Pain with end ROM (hip)
• Stiffness in younger patient unlikely to have OA
• Progresses to limping

Risk Factors =

• Pre-existing FAI
• Trauma
• Capsular Laxity
• Hip hypermobility
• Dysplasia
• DJD
• Repetitive Microtrauma
• Prior history of hip strain/trauma
• Female gender more common
• Males = more traumatic labral injuries
• Hyperabduction, Hyperextension, Hyper-flexion, and ER all place labrum at risk

(b.3) Observation

• Females = Increased hip ROM
• Males = Decreased Hip ROM
• Pain
• “Clicking”

(b.4) Examination

• (+) FADIR
• (+) FAIR test
• End range hip mobility restrictions w/ pain especially with IR
• Inguinal “clicking” and “giving way”

Question 20

Differential Diagnosis

Manual therapy & therapeutic exercise for hip labral pathologies include = ?

Answer 20

Hip Labral Pathology- Manual Therapy & Therapeutic Exercise:

Joint Mobilization:

• Perform mid-range mobilizations for all hypomobile ranges of motion.
• Avoid mobilizations that induce end-range pain.
• Consider LE traction.
• Utilize Soft tissue release techniques targeting hip flexors and deep hip rotators.

- Soft Tissue Mobilization/Myofascial Release (STM/MFR):

• Address associated soft tissue dysfunction in glutes, deep hip rotators, and psoas.
• Employ techniques such as Cross Frictional Release, Pin and Stretch, and Ischemic Compression.

Therapeutic Exercise:

- Motor:

• Begin with Isometric Control and Coordination exercises to limit end-range contact.
• Perform exercises within pain-free mid-range and end-range motion.
• Avoid overly vigorous stretching/flexibility exercises for all hip musculature.
• Strengthen glutes and short hip rotators.
• Incorporate Core stability exercises combining glute, adductor, and abductor strengthening.

Exercise Examples:

• Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, Hip flexor mobility within available pain-free range.

Sensory:

• Focus on Balance retraining for hip joint control and distal lower extremity control to minimize hip forces.
• Introduce SL exercises for sensory enhancement.

Question 21

Differential Diagnosis

Labrum functions to provide = ?

Answer 21

Labrum functions to provide

• Stability
• Shock absorptions
• Maintains fluid pressure
• Deepens the joint
• Expands surface area of the Acetabulum

Question 22

Differential Diagnosis

Five major etiologies linked to labral tears = ?

Answer 22

(a) Five major etiologies linked to labral tears:

• Trauma
• FAI
• Capsular laxity/hip hypermobility
• Dysplasia
• Degeneration

Question 23

Differential Diagnosis

What am I = ?

• Pain with FADIR and FABER
• Inguinal clicking and giving way
• Feeling of instability

Answer 23

Diagnosis and classification of labral tears, osteochondral lesions and loose bodies:

• Inguinal clicking and giving way correlated (r = 0.79) with labral tear.
• Sharp pain, especially with clicking for labral tear, helps to rule out (SN 100, −LR 0) and rule in (SP 85, +LR 6.7)16 labral tear.
• More recently, the most commonly reported locations of pain were the central groin and the lateral peritrochanteric area. The least common were the ischial tuberosity and the anterior thigh.
• Pain with FADIR and FABER
• Popping, locking or snapping
• Feeling of instability

Question 24

Differential Diagnosis

Hip Labral Tears:

• Examination Procedures = ?

Answer 24

Hip Labral Tears - Examination Procedures:

(a) FAIR test

(b) Range of motion (all planes)

• Seated, supine, and prone
• Assess for excessive mobility – stretching contraindicated.
• Assess for possible retroversion and anteversion.

(c) Strength testing -

• Flexors
• Extensors
• Abductors
• Adductors
• Rotators

Question 25

# Treatment for Labral Dysfunctions: * Focus more on **Mid** or **End-Range** = **?**

Answer 25

**Treatment for Labral Dysfunctions**: The difference treating labral tears and OA = * Avoid end range mobilizations. * Focus on mid-range control and strengthening of hip and core.

Question 26

# *Intra-Articular Hip Disorders* Hip Labral Dysfunctions: * Patient outcome measures = **?**

Answer 26

Hip Labral Dysfunctions - **Patient Outcome Measures**: * Modified Hip Harris Score * Hip Disability and osteoarthritis outcome score (HOOS) * WOMAC score * Functional testing (Trendelenburg gait pattern, squat)

Question 27

# *Differential Diagnosis* What am I = **?** * Female * Marathon runner * Anterior hip pain * Pain at rest and at night * Hip & groin pain * "Clicking" sound * (**+**) Patellar-pubic percussion test * (**+**) Fulcrum Test

Answer 27

Hip Stress Fractures: (a) **Classification**: * Bone stress injury * Stress Fracture * Pathological Fracture (b) **Characteristics**: (b.1) **Pain Pattern**: * Insidious of gradual onset of worsening hip/groin/leg pain * Increase pain during late stages of sporting event or activity * Progresses to pain at rest and at night (b.2) **Risk Factors** * Marathons / long distance running * Basic Training in the military * Female * Poor baseline physical fitness * Sharp increase in training intensity * **Female triad**: Amenorrhea, eating disorder, and decreased bone mineralization disorder. **Observation**: * Often non-specific examination * Pain at end range of mobility * Pain in **anterior hip** or **inguinal area** * 'Clicking' **Examination**: * (**+**) Patellar-pubic percussion test * (**+**) Fulcrum Test * Log rolling of LE or STLR may also aggreviate. * X-rays, MRI, Bone scan used to detect

Question 28

# *Differential Diagnosis* Hip Stress Fractures: * Treatment = **?**

Answer 28

Hip Stress Fractures: (a) **Treatment**: (a.1) **Initial Treatment**: * Non-weight bearing crutch usage 6-8 weeks * 12 weeks before resuming activity/athletics (a.2) **Joint Mobilization**: * Not indicated early in case * Later on these could be used to treat preexisting impairments * Soft tissue release to hip flexors, deep hip rotators (a.3) **STM/MFR**: * Treat associated/co-occurring soft tissue dysfunction in glutes, deep hip rotators with Cross Frictional Release * Pin and Stretch * Ischemic Compression

Question 29

# *Differential Diagnosis* Describe how to carry out the Patellar-Pubic Percussion Test = **?**

Answer 29

**[Patellar-Pubic Percussion Test](https://app.clinicalpattern.com/ortho/p8148/)**: (a) **Client Position**: * Relaxed supine position with bilateral lower extremities straight (b) **Clinician Position**: * Standing at the side of the lower extremity to be tested, directly facing the client (c) **Movement**: * The clinician places a stethoscope over the pubic tubercle on the ipsilateral side of the lower extremity being tested (right as shown). The clinician listens through the stethoscope as they tap the ipsilateral patella. Tapping and placing a tuning fork over the patella can also be used in place of tapping the patella directly. (d) **Assessment**: * A (**+**) test is a diminished percussion noted on the side of pain indicating a potential femur fracture. ## Footnote **Statistics**: * SN = 95 (92-97) * SP = 86 (78-92) * Positive (+) LR = 6.11 * Negative (−) = LR 0.07

Question 30

# *Differential Diagnosis* Describe how to carry out the Stress Fracture Test (Fulcrum Test) = **?**

Answer 30

[**Stress Fracture Test (Fulcrum Test**](https://www.youtube.com/watch?v=k2vDNa7hW2c): **Client Position**: * Relaxed sitting position on the end of the table, with bilateral feet over the edge. **Clinician Position**: * Sitting at the end of the table, directly the facing client. **Movement**: * The clinician places one forearm (left as shown) under the client’s thigh to be tested. With their other hand (right as shown), the clinician applies a downward pressure to the proximal knee. This test can be repeated in successively more proximal areas on the femur assuming the test is negative with testing of previous location. **Assessment**: * A test is considered (**+**) for ***stress fractures*** if the client reports pain with the maneuver. ## Footnote **Statistics**: * SN = 93 (NR) * SP = 75 (NR), * Positive (+) = LR 3.7, * Negative (−) LR = 0.09 * QUADAS = 5

Question 31

# *Differential Diagnosis* What am I = **?** * Insidious onset * Anterior hip pain * Pain with weight bearing * Single Hop test recreates pain

Answer 31

**Hip Stress Fracture**: * Anterior hip pain with weight bearing. * - Better with rest until fracture progresses. * Insidious onset * Need to Normalize running mechanics * Rest 6 week up to 12 months depending on the type of fracture * Assess and treat muscle imbalances at the hip and lower extremity * Address Nutritional Deficits RED syndrome (Relative Energy Deficit) * Prior history of Bone Stress Injury is number one risk factor. * Focal tenderness to Palpation <10 cm * Single Hop test recreates pain * 85% of stress fractures are missed on first x-ray so don’t rule out stress fracture even if the x-ray is clean.

Question 32

# *Differential Diagnosis* What am I = **?** * Patient reports to PT with anterior hip and groin pain after a car accident. * Presents with limited mobility and guarding.

Answer 32

Hip Dislocation: (a) **Classifications**: * Hip Dislocation  * Hip posterior dislocation  (b) **Characteristics**: (b.1) **Pain Pattern**: * Anterior hip and groin pain * Patient will come to PT after period of immobilization; potentially after surgery if boney fractures occurred to acetabulum.   * On crutches or with significant limping. (b.2) **Risk Factors**: * Congenital or Acquired  * After a total hip replacement (early on due to lack of surgical healing or later due to failure of prosthetic components) * Car Accidents * Serious falls (Football or Rugby) (b.3) **Observation**: * Pain  * Limited mobility and guarding * Patient will come in with hip abduction brace (b.4) **Examination**: * NA due to ER / hospital management of dislocation and known patholgy upon presentation to therapy.

Question 33

# *Differential Diagnosis* * What should be included in ***Manual Therapy*** & ***Therapeutic Exercise*** for Hip Dislocation **?**

Answer 33

Hip Dislocation - Manual Therapy: **Joint Mobilization**: * Avoid initially due to contraindications. Perform soft tissue release targeting hip flexors and deep hip rotators. **Soft Tissue Mobilization/Myofascial Release** (STM/MFR): * Address associated soft tissue dysfunctions in glutes, deep hip rotators, and psoas using techniques like Cross Frictional Release, Pin and Stretch, and possibly dry needling post-recovery period. * **Therapeutic Exercise: Motor**: * Progressive Mobility and Strengthening Protocol based on tissue healing. Isometric Control and * Coordination exercises, emphasizing avoidance of end-range motion, especially into adduction and flexion. * Strengthening exercises for glutes and short hip rotators. * Core Stability training integrating glute, adductor, and abductor strengthening exercises. **-** ***Exercise Examples*** : * Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, single leg step downs, Monster walks/lateral band walking, Hip flexor mobility exercises within pain-free range. **Sensory**: * Balance Retraining focusing on hip joint and distal lower extremity control to reduce hip forces. * Incorporate Single-leg exercises for proprioceptive enhancement.

Question 34

# *Differential Diagnosis* Hip Dislocations: * Typically which direction = **?**

Answer 34

**Hip Dislocations**: (**a**) Typically **posterior**, from a posterior directed force through flexed and adducted hip. * MVA * Tackled with a flexed hip and knee (**b**) Rarely anterior dislocation * Anteriorly directed force with hip in extension and external rotation. (**c**) Both types place patient at High risk for premature OA.

Question 35

# *Differential Diagnosis* Phase I and II Rehab Guidelines for Surgical Hip Dislocation = **?** | *click to view*

Answer 35

Phase I and II Rehab Guidelines for Surgical Hip Dislocation - [Link](https://bynder.uwhealth.org/m/877047b95ee89fc7/original/Rehab-Guideline-Surgical-Hip-Dislocation.pdf)

Question 36

# *Differential Diagnosis* Phase III and IV Rehab Guidelines for Surgical Hip Dislocation = **?** | *click to view*

Answer 36

Phase III and IV Rehab Guidelines for Surgical Hip Dislocation - [Link](https://bynder.uwhealth.org/m/877047b95ee89fc7/original/Rehab-Guideline-Surgical-Hip-Dislocation.pdf)

Question 37

# *Differential Diagnosis* Cellular death of bone components due to interruption of the blood supply = **?** * Transient/insidious version in youth = **?**

Answer 37

**Avascular Necrosis** / **Osteonecrosis**: * Cellular death of bone components due to interruption of the blood supply which ultimately leads to destruction of the joint articular surfaces. (**b**) Associated with * Corticosteroid use, * Bisphosphonate medications * Alcoholism, * Sickle-cell anemia * Trauma (dislocation) (**c**) Legg-Calve Perthes * Disease is an transient/insidious version of AVN in youth.

Question 38

# *Differential Diagnosis* Symptoms and Treatment of AVN = **?**

Answer 38

**Symptoms and Treatment of AVN**: * No initial symptoms with insidious or slow onset of increasing pain. * Progressive symptoms to severe pain with weight bearing and movement of the hip. * Increasing decrease in ROM * Post-dislocation * Patients with asthma, RA, or Lupus. * Usually over 50 * Total Hip Replacement is necessary in most cases

Question 39

# *Differential Diagnosis* Pediatric disorders of the hip include = **?**

Answer 39

**Pediatric Disorders of the Hip**: (a) **Hip Dysplasia**: * Shallow hip sockets which lead to dislocation of the femoral head. (b) **Legg-Calve Perthes**: * Transient osteochondrosis/necrosis of the femoral head. Insidious onset of hip pain and AVN. * Flattens femoral head. (c) **Slipped Femoral Capital Epiphysis**: * Slippage of the growth plate. Femoral head fractures off the neck of the femur. * Most are overweight or obese teenagers. (d) **Transient Synovitis of the hip**: * Benign childhood hip/groin pain * Boys > Girls (usually under 10 y/o) * Unknown cause * Self Resolves

Question 40

# *Differential Diagnosis* What am I = **?** * 14-month-old female infant * Fussiness during diaper changes, discomfort when picked up, occasional clicking sound in left hip * (**+**) Ortolani & Barlow Maneuvers positive on the left side * Asymmetric leg length, limited hip abduction

Answer 40

**Hip Dysplasia**: (a) **Classifications**: * Congenital Hip Dysplasia * Shallow hip sockets * Developmental dislocation of the hip (DDH) * Congenital Dislocation of the hip (b) **Characteristics**: (b.1) **Pain Pattern**: * Pediatric condition, often detected within the first two years. * "Clicking" - pediatric * "Snapping" - "" * "Popping" - "" * Insidious of gradual onset of worsening hip, groin, leg ***pain***. * Knee pain * In pediatric cases asymmetric leg length or groin skin fold. In **adults** * Anterior groin pain * catching and/or locking * Feeling of instability/apprehension. * Patients with DDH have larger hip muscle * Progresses to ***pain at rest and at night*** * Early onset of DJD Notes: * ***Hip Dysplasia***: Think about this as the opposite of FAI. * Instead of the hip socket being too large it is too shallow. (b.2) **Observation**: * Asymmetry in leg length * Asymmetry in hip abduction * Pain with movement of the legs (b.3) **Examination**: * **X-rays**: Lateral Center Edge Angle less than 20d * (**+**) Ortolani Manuever * (**+**) Barlow Manuever

Question 41

# *Differential Diagnosis* Hip Dysplasia: * Treatment = **?**

Answer 41

**Hip Dysplasia**: (c) **Treatment**: (c.1) **Initial Treatment**: * Bracing and orthotic appliances in pediatric cases that keep the hip in abduction. * Pavlik Harness, SWASH orthosis (standing walking and sitting hip orthosis) or Spica cast. * Weight loss can help adults Often long-term effects of dysplasia over the next 20-40 years often lead adults to have a total hip replacement.

Question 42

# *Differential Diagnosis* A congenital or developmental deformation or misalignment of the hip = **?**

Answer 42

**Hip Dysplasia**: (**a**) Hip dysplasia, and Developmental dysplasia of the hip (DDH) are a congenital or developmental deformation or misalignment of the hip. * Can present at birth or be a development problem of the hip joint. * Can be a complete dislocation of the hip/subluxation of the hip or be an abnormality of development of the hip joint. * Adults can have problems due to hip dysplasia. * **-** Noted first in adolescents due to limp or groin pain. * X-rays can reveal the hip is not centered in the socket appropriately

Question 43

# *Differential Diagnosis* You see this, what are you thinking = **?**

Answer 43

[**Hip Dysplasia**](https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/hip-dysplasia): * The socket is too shallow * The femoral head is not appropriately covered * The femoral head is misshapen and not round * Ultimately leads to **DJD** in later life

Question 44

# *Differential Diagnosis* Consequences of Hip Dysplasia = **?**

Answer 44

**Consequences of Hip Dysplasia**: * Increased Articular Load * Joint force dispersed over smaller area. * Cartilage degeneration. * **50% develop OA by 50 y/o** * Superior Migration of Femoral Head * Hypertrophic changes of labrum * Loss of joint sealing properties * **Labral pathology in 90% of cases**

Question 45

# *Differential Diagnosis* What am I = **?** * 6 y/o boy * Reports that it "hurts to walk" * Anterior & medial thigh pain * Displays psoatic limp * R leg longer than L * Pain eased w/ rest

Answer 45

**Legg-Calve Perthes Disease**: (a) **Classifications**: * [Perthes Disease](https://orthoinfo.aaos.org/en/diseases--conditions/perthes-disease) * LCPD * Idiopathic Juvenile Avascular necrosis * [Coxa Plana](https://radiopaedia.org/articles/coxa-plana-1?lang=us) (b) **Characteristics**: (b.1) **Pain Pattern**: * AVN in 4-8 year old boys that last 2+ years in physically active patients. * Pain worsens with weight bearing / IR with limping. * Loss of blood supply is temporary and reossification occurs. * Flatting of femoral head * Anterior and medial thigh pain (b.2) **Observation**: * Limping (**psoatic limp**) ER, Flexed, and adducted * Stiffness at the hip * Worse with activity better with rest * Asymmetry in leg length * Asymmetry in hip abduction while flexion and extension rarely affected * More common in Caucasians (b.3) **Examination**:

Question 46

# *Differential Diagnosis* Legg-Calve Perthes Disease: * Treatment = **?**

Answer 46

**Legg-Calve Perthes Disease**: (c) **Treatment**: * Present literature does NOT support bracing for LCP, although they are still used in some instances. * Petrie cast, Thomas splints, and Scottish-Rite Orthosis. * Surgery can be performed to improve the shape of the femoral head. * Weight loss can help adults. * Often long-term LCP patients often develop OA and progresses to total hip replacement later in life. * Caused by weakness or reflex inhibition of the psoas major muscle. * The affected legg moves in external rotation, flexion and adduction.

Question 47

# *Differential Diagnosis* What am I = **?** * 15 y/o male * IR = 20d * Leg length discrepancy * Antalgic gait w/ ER deformity * (**+**) Drehmann sign

Answer 47

[**Slipped Capital Femoral epiphysis**](https://www.ncbi.nlm.nih.gov/books/NBK538302/): (a) **Classifications**: * Slipped Cap * SCFE (b) **Characteristics**: **Pain Pattern** = * Obese teenage boys 14-15 during open growth plate of puberty. * Hip **IR** limitation * Leg length discrepancy * **Antalgic gait** w/ ER deformity * Hip weakness abductors * Requires surgery **Examination** = * X-rays and MRI are primary method of examination. * Involuntary ER with voluntary flexion of the hip is seen in SCFE (***Drehmann sign***) ## Footnote [Antalgic Gait Video](https://www.youtube.com/watch?v=W-S8Pk63YRE) * **Flex.** - 120 * **Ext.** - 30 * **Abd.** - 45 * **Add.** - 20 * **Ext. Rot.** - 45 * **Int. Rot.** - 45

Question 48

# *Differential Diagnosis* Slipped Capital Femoral epiphysis: * Treatment = **?**

Answer 48

**Slipped Capital Femoral** Epiphysis: (c) **Treatment**: (c.1) **Initial Treatment**: * The main objective = ***Avoid*** progressive displacement of the femoral head. * Hip Spicas and short & long leg cast are no longer utilized. * Surgery is the primary means of treatment for SCFE. * Patients can have complications of Chondrolysis (loss of articular cartilage) and FAI. (D) Rehab protocols are basic: * (**1**) Discarding crutches is recommended if the patient has a normal pain-free gait and can perform straight leg raise abduction without pain. * (**2**) Rehab involves strengthening within functional movement patterns, increasing range of motion, and aerobic conditioning. * (**3**) Higher end strengthening to ensuring adequate functional power for return to play or daily functioning. The time frame for return to play is variable and set by the orthopedic surgeon.

Question 49

# *Differential Diagnosis* Treatment for Pediatric Hip conditions = **?**

Answer 49

[**Treatment for Pediatric Hip conditions**](https://www.guidelinecentral.com/summaries/evidence-based-care-guideline-for-post-operative-management-of-legg-calve-perthes-disease-in-children-aged-3-to-12-years/#section-396): (**a**) Pain management * Warm whirlpool cryotherapy * Hot pack * Medications (**b**) Improving ROM * Gentle passive static stretching, gentle PROM * Dynamic ROM * Perform AROM & AAROM. (**c**) Improving skin integrity * Warm whirlpool/bath * Scar massage * Desensitization (**d**) Increasing strength exercises * Isometric * Isotonic exercises * Dlosed chain double limb (DL) exercises * Weight bearing & non-weight bearing activities (stationary bike). (**e**) Improving gait and functional mobility * Transfer training * Gait training * Assistive devices * Stair negotiation * Heel lift (**f**) Improving balance * DL stance on stable & unstable surfaces * Static single limb (SL) stance activities

Question 50

# *Differential Diagnosis* Differential diagnosis of age-related pathologies: * Pediatric age (3-12) is more indicative of = **?** * Adolescent age (12-14.5) is more indicative of = **?** * Adolescent to middle age is more likely indicative of = **?** * Older adult age is more likely indicative of = **?**

Answer 50

Differential diagnosis of age-related pathologies: (I) Pediatric age (3-12) is more indicative of * **Legg-Calve-Perthes** disease. (II) Adolescent age (12-14.5) is more indicative of * **slipped capital femoral epiphysis**. (III) Adolescent to middle age is more likely indicative of * **femoroacetabular impingement** or **labral tear**. (IV) Older adult age is more likely indicative of * **hip OA** and/or **GTPS**.

Question 51

# *Differential Diagnosis* Athletic Pubalgia: * Classifications = **?** * Characterisitics = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 51

Athletic Pubalgia: (a) **Classifications**: (b) **Characterisitics**:

Question 52

# *Differential Diagnosis* Athletic Pubalgia: * Manual Therapy = **?** * Therapeuric Exercise = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 52

Athletic Pubalgia: (c) **Manual Therapy**: (c.1) **Joint Mobilization** Dependent on Conservative vs Surgical Management. Scar massage and cross friction massage options for post-operative Athletic Pubalgia. Mobilizations for all ranges of motion Hypomobility in Hip to address surrounding joint restrictions if present SI joint mobilizations/manipulations Soft tissue release to hip flexors, abdominals, Sartorius, adductor muscles, Gracilis, deep hip rotators (c.2) **STM/MFR**: * Soft tissue release to hip flexors, abdominals, Sartorius, adductor muscles, Gracilis, deep hip rotators (d) **Therapeuric Exercise**: (d.1) **Motor**: * Core strengthening * Isometric Control and coordination exercise initially to limit end range stress on the abdominal wall. * Mid-range and end range within pain-free motion. Avoid overly vigorous stretching/flexibility exercises into spinal/trunk extension. * Strengthening of adductors, gluts, short hip rotators. * Core stability with combined glut, adductor, and abductor strengthening. * Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, Hip flexor mobility all within available pain free hip range of motion (d.2) **Sensory**: * Balance retraining for control of trunk and pelvis as well as distal LE control to allow less hip forces. * Single leg squatting and lunging as tolerated.

Question 53

# *Differential Diagnosis* Athletic Pubalgia: * What is it = **?** * Why is “Sports Hernia” is **NOT** an accurate name = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 53

[**Athletic Pubalgia**](https://pubmed.ncbi.nlm.nih.gov/33276883/#:~:text=Often%20referred%20to%20as%20a,evidence%20of%20a%20true%20hernia.): * Athletic Pubalgia is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. * “Sports Hernia” is not an accurate name. Sports Hernia has **NO** external Hernia * There is no defect in the abdominal wall and is not limited to athletes * Usually involves abdominal and/or adductor tendon pathology.

Question 54

# *Differential Diagnosis* Five signs that are indicative of Athletic Pubalgia = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 54

Five signs that are indicative of **Athletic Pubalgia**: 1. Deep groin/lower abdominal pain 2. Pain w/ sport 3. Palpable tenderness over [pubic ramus](https://www.physio-pedia.com/Osteitis_Pubis) 4. Pain w/ resisted hip adduction 5. Pain with resisted curl-up

Question 55

# *Differential Diagnosis* What am I = **?** * Males > Females * Pain in the groin, and abdominal region on exertion * Pain with sit up * Pain radiates towards the scrotum and inner thigh ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 55

**Athletic Pubalgia** / **Sports Hernia**: * Pain in the groin, abdominal region on exertion. * No palpable hernia is noted. * Typically seen in sports such as hockey, football, rugby, soccer, and track. * Males more common than females (only 3-15%). * Can have defect in abdominal wall Internal/External obliques, conjoint tendon tear, inguinal ligament tear, fascia transversalis, rectus abdominal insertion tear, entrapment of ilioinguinal nerve or genitofemoral nerve. * Present with deep, vague, groin pain/unilateral with exercise, coughing, sneezing, cutting, sprinting, pivoting, kicking, and twisting. * Pain with sit up * dull/burning in nature; and pain radiates towards the scrotum and inner thigh and can cross midline.

Question 56

# *Differential Diagnosis* Athletic Pubalgia Symptoms on Physical Examination = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 56

**Athletic Pubalgia Symptoms on Physical Examination**: * Exquisite tenderness and/or dilation of the superficial inguinal ring on direct palpation (by scrotal inversion with the little finger). * (**+**) Positive ‘**Direct Stress Test**’: palpation over the superficial inguinal ring while the patient is lying supine is uncomfortable, but while continuing to apply the same pressure over the superficial ring and getting the patient to straight-leg raise causes increased pain similar to their presenting symptoms. * Pain with resisted sit ups. ## Footnote * [Physiopedia](https://www.physio-pedia.com/Pubalgia)

Question 57

# *Differential Diagnosis* What am I = **?** * Female * Former soccer player * Pain over the pubic symphysis, that radiates to the groin * Pain w/ abduction * (**+**) Waddling gait * (**+**) Adductor squeeze test * (**+**) Spring test ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 57

[**Osteitis Pubis**](https://my.clevelandclinic.org/health/diseases/24610-osteitis-pubis): (a) **Classifications**: * Subacute periostitis of the pubic symphysis * DJD of pubic symphysis * Pubis Symphysis Diastasis during pregnancy * *This is a bone/joint problem at the pubis* (b) **Characteristics**: (b.1) **Pain Pattern**: * A common cause of pain in athletes, particularly soccer players due to overuse * Pain over the pubic symphysis that can radiate to the groin, medial thigh, or abdomen * Muscular imbalances between abdomen and hip adductors and instability in the pubis symphysis * Pain with abduction * Patients complain that the pain occurs on exertion, sprinting, cutting or twisting, side-stepping, kicking, or sitting up. (b.2) **Risk Factors**: * It has often been reported after trauma * Rheumatic disorders * Pregnancy and parturition (b.3) **Observation**: * ***Waddling gait*** can be seen (b.4) **Examination** * (**+**) Adductor squeeze test * Spring testing the pubis (bilaterally) and unilateral pressure on the ilium

Question 58

# *Differential Diagnosis* Osteitis Pubis: * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 58

**Osteitis Pubis**: (c) **Manual Therapy**: (c.1) **Joint Mobilization**: * Dependent on conservative **vs**. surgical Management. * Scar massage and cross-friction massage options for post-op. * Mobilizations for all ranges of motion to address surrounding joint restrictions if present. * SI joint mobilizations/manipulations. * Soft tissue release to hip flexors. **STM/MFR**: * Soft tissue release to hip musculature. (d) **Therapeutic Exercise**: (d.1) **Motor**: * Core strengthening * Isometric control and coordination exercise initially to limit end range stress on the abdominal wall * Mid-range and end range within pain-free motion. * ***Avoid*** overly vigorous stretching/flexibility exercises into spinal/trunk extension. * Strengthening of adductors, gluts, short hip rotators * Core stability with combined glut, adductor, and abductor strengthening * Isometrics, quadruped hip mobility, Bridges, side planks, pelvic drops, RDL’s, Single leg step downs, Monster walks/lateral band walking, Hip flexor mobility all within available pain free hip range of motion (d.2) **Sensory**: * Balance retraining for control of trunk and pelvis as well as distal LE control to allow less hip forces * Single leg squatting and lunging as tolerated.

Question 59

# *Differential Diagnosis* An inflammatory or shearing force at the symphysis pubis from muscle imbalance = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 59

**Osteitis Pubis**: * An inflammatory or shearing force at the symphysis pubis from muscle imbalance. * Rectus abdominis adductor syndrome. * More common in athletes or pregnant women: kicking sports * Treat impairments: muscle imbalances * - Adductor stretching/Core Motor motor control. * Hip muscle strength imbalance (compared bilaterally or flexors vs extensors etc.) * Hip mobility imbalances

Question 60

# *Differential Diagnosis* Four stages of Osteitis Pubis = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 60

**Four stages of Osteitis Pubis**:

Question 61

# *Differential Diagnosis* What am I = **?** * Male * Soccer player * Pain w/ hip flexion that radiates down his leg. * Pain w/ hip abduction * Pain w/ hip adduction * Pain w/ sprinting * (**+**) Adductor squeeze test [Bilateral] ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 61

**Adductor Tendinopathy** - 'Tennis elbow of the groin' **Pain Pattern**: * Groin pain, radiate down the leg. * Pain w/ hip flexion, adduction, abduction * A lump may be present in adductor muscles * Pain w/ exertion, sprinting, cutting or twisting, side-stepping, kicking, or sitting up (soccer players). (b.2) **Risk Factors**: * Males > females * 12-13% of soccer players * Co-occurring ***FAI*** * Reduced flexibility of the posterior chain muscles and/or ilio-psoas * Lumbar Hyperlordosis * Marked ***asymmetry*** and/or ***dysmetry of lower limbs***. (b.3) **Observation**: * In acute cases swelling and brusing can be present along with positioning in slight hip flexion, abduction, and ER would indicate effusion. * Reduced adductor flexibility/PROM into abduction (b.4) **Examination**: * (**+**) Adductor squeeze test (single and bilateral). * Adductor weakness on MMT

Question 62

# *Differential Diagnosis* Adductor Tendinopathy: * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 62

Adductor Tendinopathy: (c) **Manual Therapy**: (c.1) **Joint Mobilization**: * Dependent on conservative **vs**. surgical Management. * Scar massage and cross friction massage options for post-operative Athletic Pubalgia. * Mobilizations for all ranges of motion * Hypomobility in hip to address surrounding joint restrictions * SI joint mobilizations/manipulations * Soft tissue release to hip flexors, abdominals, Sartorius, adductor muscles, Gracilis, deep hip rotators (c.2) **STM/MFR** * Soft tissue release to hip flexors, abdominals, Sartorius, adductor muscles, Gracilis, deep hip rotators * Dry needling is a viable option for this condition (d) **Therapeutic Exercise**: (d.1) **Motor**: * Aquatic Therapy * Core strengthening * Progression into adductor strengthening and eccentric loading. * Isometric control and coordination exercise for adductors initially to limit end range stress on the adductor insertions * ***Avoid*** overly vigorous stretching/flexibility exercises into abduction * Strengthening of adductors, gluts, short hip rotators, and abdominal musculature * Core stability with combined glut, adductor, and abductor strengthening * Copenhagen adductor strengthening, quadruped hip mobility, bridges, side planks, pelvic drops, RDL’s, single leg step downs, monster walks/lateral band walking, hip flexor mobility all within available pain free hip range of motion (d.2) **Sensory**: * Balance retraining for control of trunk and pelvis, as well as, distal LE control to allow less hip forces. * Single leg squatting & lunging as tolerated

Question 63

# *Differential Diagnosis* **True** or **False**: * Adductor tendinopathy often coincides with osteitis pubis/athletic pubalgia = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 63

**Adductor Tendinopathy**: * Often coincides with osteitis pubis/athletic pubalgia * Usually seen in athletes in cutting and rotational sports that require eccentric loading of the hip * Decreased ROM and ratio of hip adductor vs abductor risk factors for injury * Chronic in nature * Reduction in strength preceding hip adductor injuries in Australian League Football Players * Eccentric hip Adductor program ## Footnote [10 Exercises Video](https://www.youtube.com/watch?v=mY-CmpM8JXg)

Question 64

# *Differential Diagnosis* Six classifications of tendon / muscle injuries = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 64

**Six classifications of tendon / muscle injuries**:

Question 65

# *Differential Diagnosis* Snapping Hip Syndrome: * Classifications = **?** * Characteristics = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 65

**Snapping Hip Syndrome**: (a) **Classifications**: * Coxa Saltans * Dancer’s Hip (b) **Characteristics**: (b.1) **Pain Pattern**: * Sometimes not painful but more annoying to the patient when pops are frequent. * Pain in the groin or front of hip with pop . * Pain with hip flexion and adduction (b.2) **Risk Factors**: * Females > Males * Extremes of motion with flexion and abduction (b.3) **Observation** * No acute abnormalities with most patients * Hyper flexibility (b.4) **Examination** * (**+**) Snapping hip test * (**+**) Thomas test in some patiens

Question 66

# *Differential Diagnosis* Snapping Hip Syndrome: * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 66

**Snapping Hip Syndrome**: (c) **Manual Therapy**: (c.1) **Joint Mobilization**: * Hyperflexibility may rule out joint mobilizations * IF done the focus is frequentl on the SIJD or low back not hip joint (c.2) **STM/MFR**: * Soft tissue release to hip flexors, abdominals, Sartorius, adductor muscles, Gracilis, deep hip rotators * Dry needling is a viable option for this condition (d) **Therapeutic Exercise**: (d.1) **Motor**: * Core strengthening * Hip flexor strenthing to reduce motor control problems at psoas and reduce TFL over use * Isometric Control and coordination exercise for hip flexors/Rectus initially * Avoid overly vigorous stretching/flexibility exercises into hip abduction/flexion (d.2) **Sensory**: * Balance retraining for control of trunk and pelvis as well as distal LE control for better control. * Sensory motor awareness of the leg with laser using CARS, or isometric alphabets.

Question 67

# *Differential Diagnosis* What am I = **?** * Can hear 'pop' * (**+**) Snapping hip test * (**+**) Thomas test * Pain w/ ***seated*** hip flexion & ER ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 67

[**Coxa Saltans Snapping Hip**](https://www.orthobullets.com/knee-and-sports/3096/snapping-hip-coxa-saltans): * Can snap over bony prominence * Can hear pop * Called “coxa saltans” * Seen in dancers due to extreme motions of hip movement * (**+**) Snapping hip test * (**+**) Thomas test * Seated hip flexion and ER is painful

Question 68

# *Differential Diagnosis* * Snapping Hip Treatment = **?** * What is not valuable w/ these patients = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 68

**Snapping Hip Treatment**: * Focus on strengthening the hip and improving the biomechanics. * Monster walks, hip abd. & add. strengthening. * Balance the pelvis * Soft tissue techniques may **NOT** be valuable to these individuals.

Question 69

# *Differential Diagnosis* Iliopsoas Strain: * Treatment = **?** * Management Strategies = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 69

**Iliopsoas strain**: (**a**) Iliopsoas strain or bursitis: * Repetitive activities * Assessment of flexibility * Palpation of the Iliopsoas (**b**) Treatment: * Stretching of Iliopsoas * Strengthening of the Iliopsoas (**c**) Management Strategies: (c.1) Re-education on hip flexion with transversus abdominal draw in maneuver * Progress non weight bearing to weight bearing. * Progress body weight to resistance. * Progress neuro re-education to strength training (c.2) **Treat Impairments**: * Soft tissue release to hip flexors * Contract relax stretching * Is it a mobility or stability problem?

Question 70

# *Differential Diagnosis* Greater Trochanteric Pain Syndrome: * Classifications = **?** * Characteristics = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 70

Greater Trochanteric Pain Syndrome: (a) **Classifications**: * GTPS * Hip Bursitis * Chronic Hip Bursitis * Gluteus Medius, Gluteus Minimus Tendiopathy tears * External Coxa saltans (b) **Characteristics**: (b.1) **Pain Pattern**: * Insideous Lateral Hip * Pain is worse w/ weight bearing & sidelying at night (b.2) **Risk Factors**: * 40-60 y/o typical age range * Co-occurring OA in 2/3 of patients * Higher BMI * Long distance runners (b.3) **Observation**: * Trendelenburg gait is seen less commonly with GTPS as opposed to Gluteal tears or ESOA of the hip. (b.4 ) **Examination**: * Push button sign over the trochanter is familiar pain, * (**+**) 30 second single leg stance test replicates pain, and (**+**) FABRE are the most sensitive. * De-Rotation, OBER test, and Thomas test for pain abduction may also provide information

Question 71

# *Differential Diagnosis* What does the ***manual therapy*** & ***therapeutic exercise*** for Greater Trochanteric Pain Syndrome include **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 71

[**Greater Trochanteric Pain Syndrome**](https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/greater-trochanteric-pain-syndrome/):- **Manual Therapy** & **Therapeutic Exercise**: **-** ***Joint Mobilization***: * Target capsular limitations in the hip, pelvis, and low back. * Perform mobilizations for all ranges of motion with hypomobility. * Include SI joint mobilizations/manipulations. * **Soft Tissue Mobilization/Myofascial Release** (STM/MFR): * Focus on soft tissue release for hip abductors, piriformis, and TFL (tensor fasciae latae). * Consider Dry Needling for insertional trochanteric region and gluteal muscles. **Therapeutic Exercise**: **-** **Motor**: * Incorporate Eccentric exercises for the gluteal muscles. * Strengthen adductors, glutes, and short hip rotators. * Emphasize Core strength and stability exercises. * Begin with Isometric control and coordination exercises to limit end-range stress on the abdominal wall. * Perform exercises within pain-free mid-range and end-range motion. * Avoid overly vigorous stretching/flexibility exercises into spinal/trunk extension. ***Examples*** : * Isometrics (quadruped hip mobility, bridges, side planks, pelvic drops, RDL’s), Hip flexor mobility exercises within available pain-free range. Sensory: * Implement Balance retraining for trunk and pelvis control. * Include Balance retraining for distal lower extremity control to reduce hip forces. * Introduce Single-leg squatting and lunging exercises as tolerated.

Question 72

# *Differential Diagnosis* What am I = **?** * Point tender lateral hip pain over Greater Trochanter * (**+**) FABRE test & Ober’s test * (**+**) Thomas test with hip abduction * (**+**) 30 second single limb stance test (**+** pain) ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 72

[**Greater Trochanteric Pain Syndrome (GTPS)**](https://www.ncbi.nlm.nih.gov/books/NBK557433/) or **Bursitis**: * GTPS is Chronic – not inflammation (similar to LE) formally called bursitis but now realized it is not inflammatory. * Acute Bursitis conditions are possible but require a recent onset (i.e. Bursitis does not last months or years). * Point tender lateral hip pain over Greater Trochanter (similar to push button sign in shoulder) * (**+**) FABRE test & Ober’s test * (**+**)Thomas test with hip abduction * (**+**) Derotation test * (**+**) 30 second single limb stance test (**+** pain)

Question 73

# *Differential Diagnosis* Symptoms of GTPS = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 73

**Symptoms of GTPS**: (a) **Pain**: * Lying on the ipsilateral side * Sitting * During weight bearing activities (a) **Bursitis symptoms**: * Acute/overuse athletic activities, running * Falls * Can involve iliopsoas, trochanteric, or ischial

Question 74

# *Differential Diagnosis* What am I = **?** * Lateral hip pain * (**+**) FABER test * (**-**) Imaging for hip OA ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 74

**Diagnosis of GTPS**: * Lateral Hip pain is most prominent feature * Palpation over the greater trochanter causes pain * Positive FABRE test * Negative Imaging for Hip OA

Question 75

# *Differential Diagnosis* What am I = **?** * 45 y/o * Female * Dull, lateral hip pain * Pain w/ sitting * Pain w/ resisted abduction * Trendelenburg * (**+**) OBER test * (**+**) Thomas test for pain abduction ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 75

**Gluteal Tendinopathy / Gluteal Tears**: (a) **Classifications**: * Glute max., med., and min. tears (b) **Characteristics**: (b.1) **Pain Pattern**: * Insidious, dull, lateral hip pain * Pain worse w/ sitting * WB w/side-lying at night also problematic * Pain worse w/ resisted abduction activities. (b.2) **Risk Factors**: * Late middle age women most common gluteal tears. * 40-60 y/o * Co-occurring OA in 2/3 of patients * Higher BMI * Long distance runners (b.3) **Observation**: * ***Trendelenburg*** gait is seen more commonly with Gluteal tears or ESOA (b.4) **Examination**: * (**+**) [Derotation test](https://www.youtube.com/watch?v=nwBnc3I53QY) * (**+**) [OBER test](https://www.youtube.com/watch?v=Amjv6FzDeLE) * (**+**) Thomas test for pain abduction

Question 76

# *Differential Diagnosis* Gluteal Tendinopathy / Gluteal Tears: * Manual Therapy = **?** * Therapeutic Exercise = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 76

**Gluteal Tendinopathy / Gluteal Tears**: (c) **Manual Therapy**: (c.1) **Joint Mobilization**: * Address capsular limitations in the hip, pelvis, and low back. * Mobilizations for all ranges of motions with hypomobility * SI joint mobilizations / manipulations (c.2) **STM/MFR**: * Soft tissue release to hip abductors, piriformis, TFL * Dry needling to insertional trochanteric region and gluteal muscles. (d) **Therapeutic Exercise**: (d.2) **Motor** * Eccentric exercises to the gluteal muscles * Clamshells, snow angle abd., abd. leg raises, planks with abd. * Core strengthening * Isometric Control and coordination exercise initially to limit end range stress on the abdominal wall * Mid-range and end range within pain-free motion. * ***Avoid*** overly vigorous stretching/flexibility exercises into spinal/trunk extension. * Strengthening of adductors, gluts, short hip rotators. * Core stability with combined glut, adductor, and abductor strengthening. * Isometrics (d.2) **Sensory**: * Balance retraining for control of trunk and pelvis as well as distal LE control to allow less hip forces. * Single leg squatting and lunging as tolerated.

Question 77

# *Differential Diagnosis* What am I = **?** * (**+**) Trendelenberg * Point tender lateral hip pain over Greater Trochanter or along mid glutes * (**+**) Resisted Hip Abduction test * (**+**) Derotation test * (**+**) 30 second single limb stance test * (**+**) Thomas test with hip abduction ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 77

**Gluteal Tendinopathy/Gluteal Tears**: (**a**) Gluteal tears seen in older adults & elderly * (**+**) Trendelenberg * Similar to RC tear (**b**) Point tender lateral hip pain over Greater Trochanter or along mid glutes or even into the pelvic insertions. (**c**) Mimics OA with Trendelenburg gait present in many cases. * (**+**) Resisted Hip Abduction test * (**+**) Derotation test * (**+**) 30 second single limb stance test * (**+**) Thomas test with hip abduction

Question 78

# *Differential Diagnosis* Symptoms of Gluteal Tears = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 78

**Symptoms of Gluteal Tears**: * Trendelenburg Gait pattern * Point tenderness along the glut medius insertions or muscle belly * Pain during sitting especially for long periods

Question 79

# *Differential Diagnosis* Rehab exercises to progressively load the glutes: * Low = **?** * Moderate / High = **?** * Very High = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 79

Rehab exercises to progressively load the glutes: (a) **Low**: * Clamshell (10-25) * Double limb stance (5) * Single limb balance (20) * Wall squats (9-10) * Free standing squat (10-18) (b) **Moderate / High**: * Quadruped with knee hip extension (27-32) * Bilateral bridge (15-28) * Prone hip ext with knee flexed (38) * Standing hip abduction (25-42) * Hip hikes/pelvic drop (38) * Single limb wall squat (29) * Forward lung (29-42) * Retro step up (37) * Lateral step up (38) (c) **Very High**: * Side lying hip abduction (61) * Side Bridge (74) * Single limb bridge (75) * Single leg bridge with abduction (89-103) * Monster walk/Crab walk (61) * Front step up (63) * Forward hop (61)

Question 80

# *Differential Diagnosis* Extra-Articular Nerve Entrapments: * Sciatic nerve = **?** * Lateral Femoral Cutaneous= **?** * Genitofemoral = **?** * Pudendal= **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 80

Extra-Articular Nerve Entrapments: * Piriformis: **sciatic nerve** * Femoral nerve sensitivity * Meralgia Peristhetica (**Lateral Femoral Cutaneous**): lateral anterior leg numbness/tingling. AKA tight pants syndrome * **Genitofemoral**: medial anterior hip numbness/tingling * **Pudendal**: pain but no sensory loss in genitals, perineum, or anorectal

Question 81

# *Differential Diagnosis* Meralgia Paresthetica: * What is it = **?** * Treatment = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 81

Meralgia Paresthetica - **Lateral Femoral Cutaneous Nerve**: (**a**) Tingling, numbness, and burning in the outer thigh, caused by lateral femoral cutaneous nerve irritation. * Obesity * Post operatively after THR * Tight fitting clothes * (**+**) Femoral nerve stretch test (**b**) **Treatment**: * Soft tissue work * Stretching * Femoral nerve glides * Treat Impairments

Question 82

# *Differential Diagnosis* How do you perform Lateral femoral cutaneous or femoral nerve neurodynamic testing = **?** ## Footnote *Extra-articular Hip Joint Pathology and Management*

Answer 82

**Lateral femoral cutaneous or femoral nerve neurodynamic testing**: